New Orleans Criteria and Canadian CT are 100% sensitive on finding NSGY interventional findings on CT. LOC/amnesia is required as starting point before considering studies though. New Orleans more sensitive at ANY CT finding.

Sports: Most common concussion sports are football, ice hockey, soccer, lacrosse. SCAT3 (Sports Concussion Assessment Tool) for ages > 13 (ChildSCAT3 for 5-12). Takes 15-20 minutes to complete. No return to play after concussion that day. Requires stepwise approach to go return to play – at minimum 1 week to get through steps asymptomatic.

Second Impact Syndrome: rapid edema and and death if second injury before first injury has fully resolved. Rare. First cases didn’t really have a ‘second’ impact.

Post-concussive syndrome: persistent symptoms for months/years. 20-40% have symptoms at 3 months, 15% at 1 year. Usually associated with previous migraine history, depression/anxiety. If symptoms persist for more than 3 weeks, need to see concussion clinic/specialist.

Contusion in subfrontal cortex. Associated with SAH. ICH can occur days after contusion. Usually no NSGY intervention.

Traumatic Subarachnoid Hemorrhage

Most common CT abnormality with moderate/severe TBI. CT 6-8 hours after injury more sensitive. Risk factor for early mortality.

Epidural Hematoma

Blood between skull and dura mater. Associated with middle meningeal artery. Classic presentation with head injury with LOC, followed by lucid period and then rapid decline. Strikes to lateral skull (baseball, pool stick). Biconvex hematoma in temporal region usually. Not usually crossing sutures/midline. Can lead to herniation within hours. Full recovery if hematoma evacuated prior to herniation or neuro deficits. Look for linear skull fracture along dura sinus or middle meningeal artery. Surgery for mass effect or hematoma > 30cm, or comatose.

Disruption of axonal fibers in white matter/brain stem secondary to shear forces. Usually blunt trauma. Edema can develop rapidly. CT can be normal initially but classically CT shows punctuate hemorrhage. Treatment is preventing secondary injury. Usually present in coma with ‘normal’ CT. Time will show how severe TAI is as patient either improves from comatose state.

Penetrating Injury

GCS >8 with reactive pupils have only 25% mortality. GCS < 5 100% mortality. Prophylaxis abx needed with Ceftriaxone 2g. Stab wounds very low mortality relative to GSW. Impaled objets should be left in until surgery removes. Projectiles that cross midline or center of brain, pass through ventricles or rest in posterior fossa have high mortality.

Non-Accidental Trauma

Subdural Hematoma associated with NAT in infants. Look for concurrent retinal hemorrhages. 50% of SDH were related to NAT. Only 10% accidental.

Coagulopathy

4x poorer outcome with elevated INR. ICH with warfarin has mortality of 82%. Negative CT with coagulation is reassuring though delayed hemorrhage is reported. Not necessary to observe if clinically well appearing – rebleeding/delayed bleeding can occur at 24 hours or up to 4 weeks after. TXA for systemic hemorrhage – not recommended for isolated brain injury. Idarucizumab used for reversal of dabigatran (5g total, 2.5g x 2). Antiplatelet therapy are more likely for acute bleeding over delayed bleeding like warfarin.